Journal of Sex & Marital Therapy, 31:329–340, 2005

Copyright © 2005 Brunner-Routledge

ISSN: 0092-623X print
DOI: 10.1080/00926230590950235

Physiotherapy Treatment of Sexual Pain

Disorders

TALLI YEHUDA ROSENBAUM

The Clinic for Sexual Treatment and Rehabilitation, Tel Aviv, Israel

Physiotherapists provide treatment to restore function, improve

mobility, relieve pain, and prevent or limit permanent physical
disabilities of patients suffering from injuries or disease. Women
with vulvar pain, dyspareunia, or vaginismus have limited ability
to function sexually and often present with musculoskeletal and
neurological findings appropriately addressed by a trained phys-
iotherapist. Although pelvic floor surface electromyography (sEMG)
biofeedback has been studied, the inclusion of physiotherapy in the
team approach to treating women with sexual pain disorders is
a relatively recent advancement, and its exact role is not widely
understood by doctors, mental health professionals, or laypersons.
This article will examine the supportive and often primary role of
the physiotherapist in the overlapping conditions of vaginismus and
dyspareunia.

The term “sexual pain” implies a uniquely sexual quality to the experience of
pain; in fact, it characterizes dyspareunia (Binik et al., 1999; Pukall, 2004), the
presence of a painful condition that interferes with sexual function. Recently
revised definitions of women’s sexual dysfunction avoid the term “sexual
pain” and provide clarification for two separate dysfunctions: vaginismus
and dyspareunia (Basson et al., 2004). Both vaginismus and dyspareunia are
characterized by difficulty with vaginal penetration, with phobic avoidance
and involuntary muscle contraction the main determinants of vaginismus
and pain the main diagnositic criteria of dyspareunia. Both of these condi-
tions, which often coexist clinically, are generally characterized by physical
findings such as pelvic floor hypertonus, a condition that warrants the inter-
vention of a physiotherapist. Although psychosexual approaches to sexual

Address correspondence to Talli Yehuda Rosenbaum, Haziporen 10B Bet Shemesh , Israel
99591. E-mail: tallir@netvision.net.il

329
330 T. Y. Rosenbaum

pain disorders are well documented, little research is available on the effi-
cacy of treatments such as physiotherapy. Studies available on physiother-
apy intervention for dyspareunia refer specifically to vulvodynia and vulvar
vestibulitis syndrome (VVS). VVS is one of the leading causes of dyspareu-
nia in premenopausal women (Bergeron et al., 1997; Goetsch, 1991; Harlow,
2001) and is characterized by severe pain on vestibular touch or attempted
vaginal entry, tenderness to pressure localized within the vestibule, and phys-
ical findings confined to erythema of various degrees (Friedrich, 1988). Two
retrospective studies reporting that 71% of patients rated themselves as much
improved with physical therapy (Bergeron et al., 2002; Hartmann, 2001) point
to promising potential outcomes. Studies have compared cognitive behav-
ioral therapy (CBT) to surgery in the treatment of VVS (Weijmar Schultz et al.,
1996) and compared CBT, biofeedback with a home trainer, and surgery
(Bergeron et al., 2001). However, to date, the efficacy of a combined multi-
disciplinary approach to treatment is still to be examined. Furthermore, spe-
cific protocols do not exist for many treatments, and the differences among
physiotherapy, biofeedback, and pelvic floor rehabilitation are poorly un-
derstood. This article will examine the therapeutic and often primary role of
the physiotherapist in the overlapping conditions of vaginismus, VVS, and
dyspareunia.

PHYSIOTHERAPY TREATMENT: COMPLEMENTARY OR

COMPARTMENTAL

The role of the physiotherapist in the multidisciplinary treatment of sexual

pain disorders has been addressed in the literature (Bergeron & Lord, 2003;
Holland, 2003; Mariani, 2002). The multidisciplinary model implies that treat-
ment of sexual pain disorders, understood to result from a combination of
physiological, emotional, and relational factors, responds best to physiother-
apy for the physical aspects and psychosexual treatment, including cognitive
behavioral therapy, for the relational, emotional, and sexual aspects of the
dysfunction. This simplistic and “compartmental” model, however, describes
a noncohesive approach that lacks a wholistic view by any one practitioner
and appears to break the individual patient down into her component parts,
relegating only her vaginal muscles to the physiotherapist. Multidisciplinary
treatment is best provided with a “complementary” approach best achieved
through regular communication between the physiotherapist and other treat-
ing practitioners. Complementary treatment also is best achieved when the
practitioners of the various disciplines are knowledgeable and aware of the
type and nature of the treatments provided by the other disciplines. In real-
ity, the multidisciplinary model is in itself overlapping. It is not uncommon
for the sex therapist to provide instruction in pelvic floor muscle exercises,
use of vaginal dilators, and, in the case of vulvar pain syndromes, to provide
 Physiotherapy Treatment of Sexual Pain Disorders 331

suggestions regarding baths and applications of oils. Conversely, particularly

if the physiotherapist is the primary treating practitioner, it falls upon him
or her to educate the patient regarding her anatomy, empower her to over-
come her fears, and provide suggestions regarding non intercourse-related
sexual activities. More important, however, it is the hands-on treatment, an
area considered taboo and off limits to mental health providers, that often
is the trigger in revealing areas that require further intervention. Manifested
behaviors that can be exhibited during the physiotherapy treatment session
can range from a noted inability to relax, not only in the pelvic area but
throughout the body, the need to control the direction and pace of the treat-
ment, and, in many cases, a strong expressed desire to succeed in allowing
penetration with extreme frustration displayed when anxiety prevents suc-
cess. Often, the strong desire to succeed in order to please the practitioner
is noted as well. Recognition of these traits may first occur during physio-
therapy sessions, then may be communicated to and addressed with the sex
therapist or psychotherapist on a cognitive and even psychodynamic level. A
more ominous occurrence may include a somato-emotional release, crying,
or recollection of a traumatic event such as an incident of childhood abuse
or a painful medical procedure. Although such an event may be discovered
through physiotherapy, this warrants further discussion and intervention with
a trained social worker or psychologist or sex therapist.
Conversely, physiotherapists complement treatment to sex therapy by
providing physical assurance that the patient is properly following through
on her home program and doing the physical exercises correctly. A prime ex-
ample is ensuring proper isolation and contraction of the pelvic floor muscles
in performance of exercises commonly referred to as “kegels.” Although sex
therapists typically patient instruct verbally to perform these exercises, it has
been determined that only approximately half of women who receive ver-
bal instruction in pelvic floor exercises actually perform them properly (Bo
et al., 1988; Bump et al., 1991). Sex therapists who experience frustration at
the uncertainty of patients’ correct performance of pelvic floor exercise may
find that working together with a pelvic floor physiotherapist provides the
necessary assurance that these exercises are being properly performed.
This applies to instruction in home use of dilators as well. The sex
therapist has only verbal and audiovisual tools available to teach the patient,
who often has poor awareness of her own anatomy to begin with, how
exactly to find her vaginal opening and to properly insert the dilator and
has no objective criteria by which to assess appropriate dilator size. Upon
attempting to use the dilators at home, the patient may report poor follow up
because of an inability to succeed independently. The physiotherapist fills
this void by working together with the patient and helping allay her fears
and anxieties in a safe and supportive setting. Furthermore, the sex therapist
lacks the tools to assess the connective tissue integrity of the perineal area, the
thickness of the patient’s hymen, and to teach and apply techniques such as
332 T. Y. Rosenbaum

stretching and massage, which are integral to increasing the flexibility of the
vaginal introitus. This void is best filled by a physiotherapist who is familiar
with these assessment and treatment techniques.
In her clinical approach to the treatment of VVS, Graziottin (2004) refers
to physiotherapy and suggests “two sessions consisting of general relaxation
and postural changes and eight sessions of levator ani surface EMG biofeed-
back with self insertion of a small single user sEMG sensor into the vagina.”
Although a stated lack of available physiotherapists in Graziottin’s area may
be a factor in the limited use of physiotherapy services suggested in this clin-
ical approach, it also demonstrates a lack of differentiation between phys-
iotherapy and biofeedback. Pelvic floor surface electromyography (sEMG)
biofeedback is only one of the many tools available and commonly used
by physiotherapists in the treatment of vulvar pain syndromes, and it has a
role in the assessment and treatment of vaginismus, as well (Reissing, Binik,
Khalifé, Cohen, & Amsel, 2004; van der Velde & Everaerd, 2001). Glazer
(1998) was the first to demonstrate the findings of increased pelvic floor
hypertonus and decreased pelvic floor muscle stability in vulvar pain syn-
dromes. Several studies since have demonstrated at least 50% effectiveness in
reducing VVS pain with pelvic floor biofeedback (Glazer et al., 1995; McKay
et al., 2001). Although pelvic floor biofeedback is a critical tool available to
physiotherapists in the treatment of various pelvic floor–related dysfunctions,
physiotherapy which includes the application of various hands-on exercises
and behavioral techniques and biofeedback, are not interchangeable.
The conceptual formula presented by Bergeron and Lord (2003) far
better describes the role of the physiotherapist, although the tendency to
designate only the physiological and musculoskeletal aspects of treatment to
the physiotherapist is noted. They state that the main goals of physiotherapy
are to (a) increase awareness and proprioception of the musculature, (b)
improve muscle discrimination and muscle relaxation, (c) normalize muscle
tone, (d) increase elasticity at the vaginal opening and desensitize painful
areas, and (e) decrease fear of vaginal penetration. Fitzgerald and Kotarinos
(2003) well describe physiotherapy assessment and treatment techniques in
the management of conditions of hypertonus of the pelvic floor resulting
in dyspareunia, including pelvic and vulvar pain syndromes and interstitial
cystitis.

PHYSIOTHERAPY EVALUATION OF VAGINISMUS

AND DYSPAREUNIA

Vaginismus traditionally has been defined by the Diagnostic and Statistical

Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994)
as a reflexive spasm of the outer one third of the muscles of the vagina.
Whether this refers to persistent spasm or a contractile response to attempted
penetration remains unclear, however; the validity of the existence of vaginal
 Physiotherapy Treatment of Sexual Pain Disorders 333

spasm has never been established (Reissing et al., 2004). Studies that have
directly investigated vaginal and pelvic muscle activity in women with vagin-
ismus found that women with vaginsimus had more pelvic floor hypertonus
but could not validate the presence of vaginal spasm as a diagnostic marker
(Reissing et al., 2004; van der Velde & Everaerd, 2001).
Another factor complicating the understanding of the etiology and treat-
ment of vaginismus is confirmation of diagnosis. There are few objective
defining criteria by which to diagnose vaginismus, and one recent study
found poor diagnostic agreement among physiotherapists and gynecolo-
gists (Reissing et al., 2004). Traditionally, a woman reporting inability to
allow vaginal penetration who never underwent or succeeded in undergo-
ing a vaginal exam would be diagnosed by a mental health professional
with vaginismus based on the behaviors she described, such as inability
to insert a tampon, with pain being a frequent but not necessary compo-
nent. This diagnosis is supported as well by the recent recommendations
of the International Consensus Development Conference on Female Sexual
Dysfunction, which defined vaginismus as “the persistent or recurrent dif-
ficulties of the woman to allow vaginal entry of a penis, a finger, and/or
any object despite the woman’s expressed wish to do so. There is often
(phobic) avoidance and anticipation/fear of pain. Structural and/or other
physical abnormalities must be ruled out and addressed” (Basson et al.,
2004).
In order to fulfill the final criteria, the above definition necessitates that
the patient undergo a vaginal examination by a physician or other health
professional licensed to do so. The variation of responses by the patient to
the practitioner and the variables present, such as patient’s level of anxiety
and the gender, patience level, and manner of the examiner, all contribute to
a lack of uniformity and protocol in diagnosis. Another complicating factor
is the persistent conceptualization that vaginal spasm or contraction, more
correctly referred to as “pelvic floor hypertonus” is necessarily a symptom of
vaginismus. In fact, in the absence of patient anxiety or physical withdrawal
during the examination, it is more likely associated with conditions such
as VVS, pelvic pain, or dyspareunia. In clinical practice, therefore, it is not
uncommon for a patient to be referred to physiotherapy with “severe vagin-
ismus” who presents with significant levator muscle hypertonus but who was
in fact quite cooperative for the exam and exhibited no distress other than
positive findings of pain and tenderness in specific areas of palpation. Con-
versely, patients referred with diagnoses other than vaginismus can present
to physiotherapy with significant anxiety, exhibiting behaviors of leg cross-
ing or buttock lifting in order to avoid examination. Furthermore, variations
among practitioners in the pressure applied to tender areas may produce
varied subjective responses because hypersensitivity to touch and lowered
pain thresholds may be present (Lowenstein et al., 2004; Pukall, Binik, &
Khalifé, 2004).
334 T. Y. Rosenbaum

Because of the lack of consensus regarding diagnosis, the variation in

presentation, and the frequently overlapping of symptoms of vaginismus
with other conditions such as vestibulitis (Abramov, Wolman, & David, 1994;
de Kruiff, Ter Kuile, Weijenborg, & van Lankveld, 2000), the physiother-
apy rule of thumb in assessment and management is to treat the patient,
not the diagnosis, and to address the findings. Even in cases of “pure”
vaginismus, patient presentations are varied. Some women with vaginis-
mus may report that they feel completely sexually uninhibited with their
partner, have arousal and orgasms, and can enjoy themselves but are un-
able to allow penetration. In fact, they may demonstrate completely nor-
mative sexual behavior until the actual attempt to insert a finger or dila-
tor into the vagina. On the other side of the spectrum are patients who
have little experience with sexual activity, and recoil at any touch; clearly,
fear of penetration is but one of the many anxieties they may contend with
regularly.
Given the variation of sexual feelings, experiences, and backgrounds of
women referred with vaginismus and its overlap with conditions of dyspare-
unia and vulvar pain syndromes, a very thorough medical and sexual history
is integral to assessment, treatment, and determination of the influence of
psychosexual, cultural, educational, and psychodynamic factors. The history
includes gathering information regarding the patient’s chief complaint with
which she presents. In most cases, patients with vaginismus seek treatment
when it becomes apparent that this condition interferes with sexual inter-
course, and the ability to have sexual intercourse is the goal of treatment.
However, the inability to allow penetration extends to other nonsexually re-
lated functional activities as well, such as inserting a tampon or undergoing a
gynecological exam. Moreover, patients with a burning vulva may primarily
be seeking relief of their symptoms and may or may not even be sexually
active. Whether sexual activity is a goal of treatment is determined together
with the patient.
When the presenting complaint is pain with penetration or attempted
penetration, a thorough pain assessment is necessary. Location of pain and
its characteristics are the strongest predictors of its organicity (Meana, Binik,
Khalifé, & Cohen, 1997). The pain description (burning versus aching, diffuse
versus local, spontaneous versus provoked) reflects its somatic, visceral, or
neuropathic nature and will help determine direction for physical examina-
tion and treatment. It is important to determine at what point the pain occurs;
if it is superficial or deep, if it occurs with arousal or orgasm, and if the pain
can be alleviated and how. Comorbidity with vulvar pain syndromes has
been reported with interstitial cystitis (IC), pelvic pain, and urinary urgency
and frequency (Jamieson & Steege, 1996; Doggweiler-Wiygul & Wiygul, 2002;
Gunter, 2000). These conditions are related to muscle hypertonus and mus-
cle trigger point irritability and should be addressed concurrently (Travell &
Simons, 1992).
 Physiotherapy Treatment of Sexual Pain Disorders 335

OBSERVATION AND MUSCULOSKELETAL EXAMINATION

The musculoskeletal exam consists of the following: (a) assessment of pos-

ture, mobility, and strength; (b) observation of the patient’s movement
and breathing; (c) palpation for areas of tightness and decreased mobility;
(d) evaluation of the viscera to note hypomobile areas; (e) checking of spinal,
sacral, and pelvic alignment; and (f) muscle testing for length, strength, and
trigger points.
General observation reveals the patient’s posture, breathing, and gait.
Chronic anxiety, for example, is manifested by increased muscle tone of
the abdominal oblique muscles, placing increased intraabdominal pres-
sure on the pelvic floor and creating dyssynergic breathing patterns and
pelvic floor muscle dysfunction. Careful assessment is made of the strength,
length, and mobility of the pelvic and lumbar joints, as well as the sur-
rounding musculature of the pelvis and hips. A typical musculoskeletal pre-
sentation of patients with vaginismus is tight hip flexors and adductors—
muscles related to posture of “pulling in.” It is interesting to note that
they are commonly found to present with weak, undeveloped pelvic floor
muscles, which is revealed when they are asked to perform an active
contraction.

VULVAR AND PELVIC FLOOR EXAMINATION

The physiotherapist’s assessment of the vulva differs from a gynecological

examination. Both the external and internal exam focus on the mobility and
integrity of the muscular, fascial, and connective tissue components. The
vulvar and pelvic floor exam consists of the following: (a) observation of the
vulva, perineum, and anus to note areas of redness, raised areas, scar tissue,
or edema; (b) palpation to note areas of tenderness to touch; (c) internal
exam to assess pelvic floor muscle tension and tightness, tone, range of
motion, and hymenal presence and thickness; (d) assessment of internal
muscle trigger points; (e) determination of the integrity of the pelvic organs
and possible presence of prolapse of the bladder, uterus, or rectocele; and
(f) anorectal internal exam.
Physiotherapists assess pelvic floor muscle tone with both manual ex-
amination and sEMG assessment with a vaginal probe. The presence of
pelvic floor hypertonus and decreased resting and working level muscle
stability, evidenced by a high standard deviation, has been associated with
VVS (Glazer, 1998). Pelvic floor hypertonus has been associated with other
dyspareunia-related conditions such as IC, levator ani syndrome, and proctal-
gia fugax (Kotarinos, 2003). Pelvic floor muscle assessment determines mus-
cle tone at work and at rest, contractile amplitude, reaction times, and muscle
stability.
336 T. Y. Rosenbaum

PHYSIOTHERAPY TREATMENT

Physiotherapists provide services that help restore function, improve mo-

bility, relieve pain, and prevent or limit permanent physical disabilities of
patients suffering from injuries or disease. They restore, maintain, and pro-
mote overall fitness and health (U.S. Dept. of Labor, 2004). Physiotherapists
treating patients suffering from illness or disease address the sensory, in-
flammatory, neurological, and musculoskeletal aspects of the disease and
their effect on function. They choose specific techniques, guided by the
findings of the history and examination. In conditions of pain due to local
inflammation, reduced sensory pain threshold, neuropathic conditions, or a
combination thereof, sensory rehabilitation provides relief of symptoms by
raising the pain threshold and “accustomizing” the affected area to touch. In
VVS, the vulvar vestibule has been found to have an increase in nocicep-
tors and mast cells (Bohm Starke et al., 2001; Bornstein et al., 2002). Other
studies have pointed to a decreased pain threshold and more acute pain per-
ception in patients with VVS (Pukall, 2002; Granot, Friedman, Yarnitzsky, &
Zimmer, 2002). Patients with VVS often demonstrate behaviors of avoidance
regarding allowing direct touch or contact to the area, which hypersensi-
tizes the area even more. Introduction of daily light touch by the patient
herself with applications of vitamin E oil provide the therapeutic benefits of
increasing proprioception and body awareness, and decreasing local tissue
hypersensitivity.
Physiotherapists apply various hands-on techniques to treat muscu-
loskeletal abnormalities, postural and skeletal asymmetries, and soft tissue
immobility. Trigger points are discrete, focal, hyperirritable spots located in
a taut band of skeletal muscle (Alvarez & Rockwell, 2002; Simons & Travell,
1983; Travell & Simons, 1992). They produce pain locally and in a referred
pattern and often accompany chronic musculoskeletal disorders. The appli-
cation of trigger point massage in the pelvic area and transvaginally has been
described in the treatment of pelvic pain and IC (Weiss, 2001) and for the
treatment of vulvar pain syndromes (Fitzgerald & Kotarinos, 2003). Additional
techniques include massage and connective tissue and scar tissue release. Os-
teopathic techniques such as visceral and urogenital manipulation, taught to
physiotherapists in advanced training courses, are effective techniques, as
well (Baral, 1993). Other techniques, available to the physiotherapist treating
musculoskeletal dysfunction associated with pelvic and vulvar pain include
muscle energy, contract/relax, and passive and resisted stretching designed
to normalize postural imbalances, improve blood circulation in the pelvic and
vulvar area, and improve pelvic and vulvar mobility. Dilators are used not
only to help overcome penetration anxiety but to stretch the introital open-
ing. Perineal dilators, designed for predelivery perineal stretching in women
hoping to avoid episiotomy, is useful for introitus and perineal stretching in
women with introital tightness (Cohain, 2004).
 Physiotherapy Treatment of Sexual Pain Disorders 337

Pelvic floor sEMG biofeedback for the treatment of VVS has been well
studied (Glazer et al., 1995; Bergeron et al., 2001; McKay et al., 2001). The
goals of sEMG biofeedback are to normalize pelvic floor muscle tone, de-
crease hypertonus, and improve contractile and resting stability. Other modal-
ities available to the physiotherapist include pelvic floor electrical stimulation.
Use of pelvic floor electrical stimulation has been studied in the treatment
of levator ani hypertonus and pelvic pain (Fitzwater et al., 2003) and has
been reported to successfully improve pelvic floor muscle strength and re-
duce pain in the treatment of VVS (Nappi et al., 2003). The use of perineal
ultrasound—the application of deep heat produced by frequency waves—
for the treatment of dyspareunia has also been reported in the literature
(Hay-Smith, 2000).

CONCLUSION

Sexual pain disorders are pain disorders that interfere with sexual activity.
Conditions resulting in painful sexual intercourse are often multisystemic and
respond well to a multidisciplinary approach to treatment (Graziottin, 2001).
The systems involved, including the vascular, musculoskeletal, and neurolog-
ical, are well addressed with physiotherapy, which includes a combination
of hands-on techniques, exercises, behavioral approaches, biofeedback, and
electrical and heat modalities. Although issues such as effect on the relation-
ship, and lifelong or acquired low libido and arousal are best addressed in
sex therapy, physiotherapists are in a unique position to provide adjunctive
treatment for overcoming anxiety related to vaginal penetration. Physicians
recognizing and treating women presenting with vaginismus, VVS, and dys-
pareunia should consider physiotherapists as vital members of the interdis-
ciplinary team.

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